1063497972 NPI number — VERNON DISCOUNT DRUG INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063497972 NPI number — VERNON DISCOUNT DRUG INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERNON DISCOUNT DRUG INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063497972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERNON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32462-0505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-535-2803
Provider Business Mailing Address Fax Number:
850-535-0150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3248 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERNON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32462-2223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-535-2803
Provider Business Practice Location Address Fax Number:
850-535-2803
Provider Enumeration Date:
12/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PAUL
Authorized Official First Name:
JACK
Authorized Official Middle Name:
GARY
Authorized Official Title or Position:
OWNER PHARMACIST
Authorized Official Telephone Number:
850-535-2803

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PH11020 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100893500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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